Age Not the Only Explanation for Sex Gap in PCI Care, Outcomes

Younger women below 55 years had worse long-term survival compared with age-matched men.

Age Not the Only Explanation for Sex Gap in PCI Care, Outcomes

When older age is taken out of the equation, women undergoing PCI still face suboptimal care compared with men, Australian registry data indicate.

An analysis restricted to patients younger than 55 showed more cardiovascular risk factors and delays, less radial access, and less-comprehensive medical therapy among women. Perhaps most importantly, the younger female patients faced higher long-term mortality than their male counterparts, even after adjustment for potential confounders. The increased death risk wasn’t seen at ages 55-70 or beyond.

The fact that women with cardiovascular disease aren’t getting the same treatment—or achieving the same outcomes—as men will come as no surprise based on years of data. But many in cardiology had speculated that some of the imbalance was related to female patients presenting at an older age, when they tend to have more comorbidities.

Stephen J. Duffy, MBBS, PhD (Alfred Hospital, Melbourne, Australia), the study’s senior author, told TCTMD that this is the latest among several reports from their group intended to “further tease out the reasons for the disparities in health outcomes for women with cardiovascular disease.” For this paper, published as a research letter in the Journal of the American College of Cardiology, the investigators compared age-matched groups of male and female PCI patients from a large, real-world database.

What they found, Duffy said in an email, suggests “that the overall differences in treatment and outcomes for women is not due to older age and excess comorbidities.”

For women younger than 55 years, “I think that there is room for improvement in care at every stage of treatment, including prevention, recognition of cardiovascular disease, and guideline-directed treatment,” he commented. “This involves discarding biases (ie, ‘young women don’t get heart disease’), as well as uniform use of evidence-based treatments. Whether the latter is through routine use of guidelines (ie, protocols) or greater education of physicians depends on the setting. However, women also need to be educated that heart disease is not a disease only of men.”


Using data from the Victorian Outcome Registry (VCOR), the researchers identified 24,718 patients who underwent PCI for MI between 2013 and 2018. Women made up 23% of the cohort as a whole, but the proportion differed by age: just 16% of those younger than 55 and 20% of those aged 55-70 years were female, as compared to 34% of those 70 and older.

Comorbidity burden also differed by age. In the eldest group, the only differences were higher rates of peripheral vascular disease, previous PCI, and coronary artery bypass grafting among men versus women. In the younger groups, women tended to have higher body mass index as well as greater prevalence of diabetes and cerebrovascular disease than men. Renal dysfunction (estimated glomerular filtration [eGFR] rate < 60 mL/min/1.73 m2) was more common for female patients at all ages.

For women vs men presenting with STEMI, the youngest group saw longer symptom-to-door time (median 210 vs 185 minutes) and door-to-device time (median 75 vs 67 minutes; P < 0.001 for both). The same delays weren’t seen at ages 70 or older. Women younger than 55 also were less likely to be prescribed an ACE inhibitor/ARB and statin therapy at discharge. In the eldest group, all medical therapy was similar apart from statin use. For NSTEMI patients, the youngest women also were less likely to be discharged on beta-blockers and statins.

Regardless of age or presentation, women had more infrequent use of PCI via the radial artery than men.

Unadjusted mortality at a mean follow-up of 2.5 years was higher for women aged below 55 than for similarly aged men (5.0% vs 3.2%; P = 0.012). The same disparity was seen for women older than 70 (21% vs 18%; P= 0.022) but not for those aged 55-70 years (7.3% vs 6.4%; P = 0.18).

Multivariable analysis confirmed the sex difference in mortality for the youngest age group and also showed associations with regard to STEMI presentation, diabetes, LVEF, and eGFR.

Long-term All-Cause Mortality Risk


Adjusted HR

95% CI

Women vs Men

     Age < 55

     Age 55-70

     Age > 70


















     < 35%












The wider mortality gap in the below-55 group “may relate to underrecognition that MI occurs in younger women, both by the patients themselves (delayed presentation) and the health system,” suggested Duffy, citing a 2021 paper he co-authored on that topic. “There may be an element of bias here, but biology may also play a part. Perhaps it is both.”

Duffy and lead author Misha Dagan, MD (Alfred Hospital), agreed that there are opportunities for improvement along the continuum of care at every stage of treatment and follow-up.

For primary prevention specifically, Dagan pointed out that the “higher comorbidity burden captured amongst younger women compared to aged-matched men suggests these women are well linked in with primary care physicians in order to be labeled with such comorbidities. [Thus,] while an acute coronary syndrome event may be the first time these women meet a specialist cardiologist, there remains a large role for primary healthcare providers to focus on risk reduction in the first instance.”

The solution at this stage is “multifactorial,” she said, “and relies on empowering young women to advocate for their own cardiovascular risk reduction as well as further awareness amongst primary healthcare providers.”

Once patients have presented to the hospital, there are further challenges, Duffy noted. “It is obviously complex, as it is well known that women often present with nonclassical symptoms (eg, dyspnea rather than chest pain), so the initial triage of patients in the ED may be incorrect.  Protocols that are gender agnostic for treatment of MI may be part of the solution, but I favor education, starting with medical students.”

Randomized trials of protocol-driven care could also be conducted to see which strategies are most effective at improving treatment and outcomes, he suggested. Electronic medical records (EMRs), for instance, could include prompts for guideline-directed therapies. “None of us love EMRs, but they can be used to educate junior medical staff that may be less familiar with what is needed for each patient,” he observed.

  • VCOR is supported by the Victorian Government and Monash University.
  • Duffy’s work is supported by a National Health and Medical Research Council of Australia grant.
  • Dagan reports no relevant conflicts of interest.